VA/National Clinician Scholars Program, VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, MI; Section of Plastic Surgery, Michigan Medicine, Ann Arbor, MI.
Section of Plastic Surgery, Michigan Medicine, Ann Arbor, MI.
J Hand Surg Am. 2021 Jul;46(7):544-551. doi: 10.1016/j.jhsa.2021.02.022. Epub 2021 Apr 16.
The U.S. Department of Veterans Affairs (VA) health care system monitors time from referral to specialist visit. We compared wait times for carpal tunnel release (CTR) at a VA hospital and its academic affiliate.
We selected patients who underwent CTR at a VA hospital and its academic affiliate (AA) (2010-2015). We analyzed time from primary care physician (PCP) referral to CTR, which was subdivided into PCP referral to surgical consultation and surgical consultation to CTR. Electrodiagnostic testing (EDS) was categorized in relation to surgical consultation (prereferral vs postreferral). Multivariable Cox proportional hazard models were used to examine associations between clinical variables and surgical location.
Between 2010 and 2015, VA patients had a shorter median time from PCP referral to CTR (VA: 168 days; AA: 410 days), shorter time from PCP referral to surgical consultation (VA: 43 days; AA: 191 days), but longer time from surgical consultation to CTR (VA: 98 days; AA: 55 days). Using multivariable models, the VA was associated with a 35% shorter time to CTR (AA hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.52-0.82) and 75% shorter time to surgical consultation (AA HR, 0.25; 95% CI, 0.20-0.03). Receiving both prereferral and postreferral EDS was associated with almost a 2-fold prolonged time to CTR (AA HR, 0.49; 95% CI, 0.36-0.67).
The VA was associated with shorter overall time to CTR compared with its AA. However, the VA policy of prioritizing time from referral to surgical consultation may not optimally incentivize time to surgery. Repeat EDS was associated with longer wait times in both systems.
Given differences in where delays occur in each health care system, initiatives to improve efficiency will require targeting the appropriate sources of preoperative delay. Judicious use of EDS may be one avenue to decrease wait times in both systems.
美国退伍军人事务部（VA）医疗保健系统监测从转介到专科就诊的时间。我们比较了 VA 医院及其学术附属医院（AA）进行腕管松解术（CTR）的等待时间。
我们选择了 2010 年至 2015 年在 VA 医院及其学术附属医院（AA）进行 CTR 的患者。我们分析了从初级保健医生（PCP）转介到 CTR 的时间，该时间分为从 PCP 转介到外科咨询和从外科咨询到 CTR。电诊断测试（EDS）根据外科咨询进行分类（转诊前与转诊后）。多变量 Cox 比例风险模型用于检查临床变量与手术部位之间的关联。
在 2010 年至 2015 年期间，VA 患者从 PCP 转介到 CTR 的中位数时间更短（VA：168 天；AA：410 天），从 PCP 转介到外科咨询的时间更短（VA：43 天；AA：191 天），但从外科咨询到 CTR 的时间更长（VA：98 天；AA：55 天）。使用多变量模型，VA 与 CTR 时间缩短 35%（AA 危险比 [HR]，0.65；95%置信区间 [CI]，0.52-0.82）和外科咨询时间缩短 75%（AA HR，0.25；95% CI，0.20-0.03）相关。接受转诊前和转诊后 EDS 两者都与 CTR 时间延长近 2 倍相关（AA HR，0.49；95% CI，0.36-0.67）。
与 AA 相比，VA 与 CTR 的总时间更短。然而，VA 将从转介到外科咨询的时间优先化的政策可能无法最佳激励手术时间。在两个系统中，重复 EDS 与更长的等待时间相关。
鉴于每个医疗保健系统中延迟发生的位置不同，提高效率的举措将需要针对术前延迟的适当来源。明智地使用 EDS 可能是降低两个系统等待时间的一种途径。
